Under the Millennium Development Goals (MDGs), United Nations (UN) Member States reported progress on the targets toward their general citizenry. This focus repeatedly excluded marginalized ethnic and linguistic minorities, including people of refugee backgrounds and other vulnerable non-nationals that resided within a States’ borders. The Sustainable Development Goals (SDGs) aim to be truly transformative by being made operational in all countries, and applied to all, nationals and non-nationals alike. Global migration and its diffuse impact has intensified due to escalating conflicts and the growing violence in war-torn Syria, as well as in many countries in Africa and in Central America. This massive migration and the thousands of refugees crossing borders in search for safety led to the creation of two-tiered, ad hoc, refugee health care systems that have added to the sidelining of non-nationals in MDG-reporting frameworks.

1. COMMENTARY Open Access
The right to health of non-nationals and
displaced persons in the sustainable
development goals era: challenges for
equity in universal health care
Claire E. Brolan1,2
, Lisa Forman2
, Stéphanie Dagron3
, Rachel Hammonds4
, Attiya Waris5
, Lyla Latif5
and Ana Lorena Ruano6,7*
Abstract
Introduction: Under the Millennium Development Goals (MDGs), United Nations (UN) Member States reported
progress on the targets toward their general citizenry. This focus repeatedly excluded marginalized ethnic and
linguistic minorities, including people of refugee backgrounds and other vulnerable non-nationals that resided
within a States’ borders. The Sustainable Development Goals (SDGs) aim to be truly transformative by being made
operational in all countries, and applied to all, nationals and non-nationals alike. Global migration and its diffuse
impact has intensified due to escalating conflicts and the growing violence in war-torn Syria, as well as in many
countries in Africa and in Central America. This massive migration and the thousands of refugees crossing borders
in search for safety led to the creation of two-tiered, ad hoc, refugee health care systems that have added to the
sidelining of non-nationals in MDG-reporting frameworks.
Conclusion: We have identified four ways to promote the protection of vulnerable non-nationals’ health and well
being in States’ application of the post-2015 SDG framework: In setting their own post-2015 indicators the UN
Member States should explicitly identify vulnerable migrants, refugees, displaced persons and other marginalized
groups in the content of such indicators. Our second recommendation is that statisticians from different agencies,
including the World Health Organization’s Gender, Equity and Human Rights programme should be actively
involved in the formulation of SDG indicators at both the global and country level. In addition, communities, civil
society and health justice advocates should also vigorously engage in country’s formulation of post-2015 indicators.
Finally, we advocate that the inclusion of non-nationals be anchored in the international human right to health,
which in turn requires appropriate financing allocations as well as robust monitoring and evaluation processes that
can hold technocratic decision-makers accountable for progress.
Keywords: Sustainable development goals, Millennium development goals, Refugees, Health of non-nationals,
Right to health
* Correspondence: Ana.lorena.ruano@cih.uib.no
6
Center for the Study of Governance and Equity in Health Systems
Guatemala City, Guatemala, Guatemala
7
Center for International Health, University of Bergen, Bergen, Norway
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Brolan et al. International Journal for Equity in Health (2017) 16:14
DOI 10.1186/s12939-016-0500-z

2. Background
Under the Millennium Development Goals (MDGs),
United Nations (UN) Member States reported pro-
gress on the targets toward their general citizenry.
This focus repeatedly excluded marginalized ethnic
and linguistic minorities, including people of refugee
backgrounds and other vulnerable non-nationals that
resided within a States’ borders [1, 2]. With multilateral
and bilateral impetus on scaling-up MDG achievement in
low-income countries, the health inequities experienced
by vulnerable and poor minoritiesin middle and high-
income nations were further overlooked, this includes
non-nationals [3]. Recognizing this inequity, in October
2013 the Goals for Governance and Global Health
(Go4Health) research consortium called for the post-2015
Sustainable Development Goals (SDGs) agenda to be truly
transformative by being made operational in all countries,
and applied to all, nationals and non-nationals alike [4].
Go4Health explicitly asked governments to begin pro-
gressively meeting their minimum core right to health
obligations for vulnerable populations, such as non-
nationals, displaced persons and minorities that live
within their borders, and to be responsive to in-country
health challenges and inequities resulting from cross-
border human movement.
Global migration and its diffuse impact have intensi-
fied due to escalating conflicts and growing violence in
war-torn countries such as Syria, as well as in many
countries in Africa and in Central America. The mass
migration of thousands of refugees crossing borders in
search for safety has led to many countries creating two-
tiered, ad hoc, refugee health care systems that have
contributed to the sidelining of non-nationals in MDG-
reporting frameworks [2]. This situation underlines the
importance of including vulnerable non-nationals in glo-
bal development frameworks like the SDGs. Thousands
of minors from the northern triangle of Central America
have made the perilous crossing into the United States,
and one million refugees crossed the Mediterranean to
enter Europe in 2015. The United Nations High Com-
missioner for Refugees (UNHCR) reported worldwide
displacement had reached the highest ever-recorded level,
with 59.5 million people now of concern [5–7]. This is not
a problem of ‘the west’, that given Turkey, Pakistan,
Lebanon, Iran, Ethiopia and Jordan each host between
1.59 million and 654,100 displaced individuals [5, 6]. Of
the 59.5 million people displaced in 2015, approximately
one-third (19.5 million) were refugees, the bulk of whom
(86%) reside in developing regions, with least developed
countries hosting 25% of that total [5, 6].
Tens of millions more still lie outside UNHCR’s mandate,
and they are not counted in the 59.5 million figure; these
are the undocumented or irregular migrants who have
crossed borders for equally complex reasons. These human
beings are trying to escape from poverty, from environmen-
tal and climate instability, rapid urbanization, human traf-
ficking, slavery, and unimaginable levels of violence [8, 9].
According to UNHCR, the fifteen new or ongoing conflicts
throughout the world in the past 5 years only compound
these factors. . The Syrian crisis highlights the complex
interconnection between war, refugee status and the un-
documented movement of people, and is responsible for a
large proportion of this burden [5]. Both the refugees
escaping from Syria, as well as the minors from Central
America are easy prey for international criminal gangs, who
engage in human smuggling and trafficking, as well as mul-
tiple forms of exploitation of these vulnerable populations
[7]. Often those on the move are people in extremely
vulnerable positions and are routinely denied the means to
take control of their health as well as of their life circum-
stances [10]. Improving the human health and dignity of
these and other groups is and will be a transnational
challenge that can only be addressed through global action,
solidarity, recognition and commitment by the global
community to realize the post-2015 SDG catchcry of
‘leaving no one behind’ [11, 12].
The health challenges of people on the move
It is important to note that each person that is traversing
the world’s borders in challenging circumstances differs
in health status and in need. Studies usually focus on
healthcare issues and barriers for people in refugee
camps or those seeking asylum in high-income nations.
Studies on refugee camps in resource-poor settings fre-
quently describe overcrowding, poor hygiene and sanita-
tion, poor water quality, food insecurity, discrimination,
and issues of violence (including sexual violence). As a
result, camp inhabitants experience multimorbidities,
which may include communicable diseases and parasitic
infections, under-management of chronic health condi-
tions, under-immunization, and inadequate nutrition. Al
of this can result in delayed growth and development in
children, as well as sexual and reproductive health prob-
lems, among many other conditions. Meanwhile, the litera-
ture on refugee health in high-income settings routinely
identifies the need for on-arrival health-care screening, as
well as identifies the vulnerability of adults and children,
particularly unaccompanied minors, to develop mental
health problems. Often, a government’s denial of health
services and basic social determinants of health is tied to
promotion of state securitization and inter-related policies
regulating cross-border movements of people [13], but
little consideration seems to be given to the migrants and
refugees themselves.
What do the sustainable development goals offer?
It is worth emphasizing that the SDGs, which consist of
17 goals and 169 associated targets, is intended as a
Brolan et al. International Journal for Equity in Health (2017) 16:14 Page 2 of 4

3. universal agenda for all people in all segments of society,
in developed and developing countries alike [11]. This
means that vulnerable groups such as refugees, internally
displaced persons and migrants deserve not only consid-
eration but also health systems that are responsive to
their specific health needs. In the post-2015 UN reso-
lution governments have collectively pledged that the
SDGs are to include people whose backgrounds are
marred by persecution, poverty, extremism, conflict, vio-
lence, humanitarian crises, natural disaster, and forced
displacement. However such affirmative statements, and
those on access to education and humane treatment of
persons regardless of migration status, are laudable but
not enough.
Governments will likely shape their SDG policies and
programs to align with their post-2015 commitments in
the SDG metrics framework instead of the commitments
found in the UN resolution’s preamble or broader dec-
laration. This reaffirms the growing concern as to the
real possibility that the most poor, socially isolated, and
disadvantaged groups the SDGs seek to capture will be
overlooked and ignored by a multitude of countries and
their development partners when it comes to planning,
implementation, monitoring, and reporting within the
SDG framework. These are some of the world’s most
marginalized people for whom the post-2015 SDGs most
matter. If vulnerable migrants, the displaced and other
at-risk populations such as victims of human trafficking
lack affirmative and repeated identification within the
SDG metrics framework, their needs and rights will be
ignored in post-2015 development planning initiatives
for the next 15 years. In 2015 and 2016, multiple coun-
tries introduced regressive measures that undermined
access to healthcare for vulnerable non-nationals.
Recommendations
We have identified four ways to enhance the protection
of vulnerable non-nationals’ and internally displaced per-
son’s health and well-being in States’ application of the
post-2015 SDG framework. All four recommendations
are interdependent and intertwine: not one of the four
paths forward that we identify can be effectively achieved
without implementation of the other three. Our recom-
mendations are as follows:
a) In setting their own post-2015 indicators, UN
Member States should explicitly identify and
include vulnerable non-nationals, displaced
persons and other marginalized groups in
the content of such indicators;
b) The Inter-Agency and Expert Group on SDG
Indicators (IAEG-SDGs) should continue to
encourage states and researchers to collect data
that will help governments to develop data
disaggregation measures and tools that specifically
include such populations;
c) Statisticians from key multilaterals, together with
community and civil society representatives
(among other actors), should be actively involved
in the formulation and monitoring of SDG
indicators at both the global and country-level;
d) The inclusion of non-nationals and internally
displaced persons in the post-2015 SDG framework
must be anchored in the international human right
to health.
Our first recommendation is that in setting their own
post-2015 indicators, UN Member States from devel-
oped and developing nations should explicitly identify
and include vulnerable non-nationals, displaced persons
and other marginalized groups in the content of such
indicators. States should be guided by the overall global
goal, while also taking into account their national circum-
stances [12]. We secondly recommend that the IAEG-
SDGs should continue to encourage states, the multilat-
erals, and researchers to collect data that will help govern-
ments to develop data disaggregation measures and tools
that specifically include such populations. In addition,
national SDG indicators need to incorporate fiscal alloca-
tion of resources for emergency and non-emergency level
for these specific groups. This is particularly important in
the context of SDG 3, which seeks to ensure healthy lives
for all, specifically Target 3.7 (“… ensure universal access
to sexual and reproductive health-care services…”) and
Target 3.8 (“Achieve universal health coverage…”).
Our third recommendation is that statisticians from
UNHCR, IOM, and the World Health Organization’s
Gender, Equity and Human Rights programme should
be actively involved in the formulation of SDG indicators
at both the global and country-level. This is likely to in-
volve additional financial and human resource for these
international agencies. However, it is well worth the short-
term investment. In addition, communities, civil society,
foundations and philanthropic organisations, private orga-
nizations, and development banks, together with health
justice advocates, should also vigorously engage in each
country’s formulation of post-2015 indicators. We encour-
age such actors to reject indicators that do not identify
and include the world’s most vulnerable. If country targets
and indicators do not best address the “dimensions of
inequality that are particularly relevant to each coun-
try’s internal borders” [3] - which includes the health
and related inequalities experienced by vulnerable non-
nationals - then we must advocate countries return to
the SDG metrics drawing-board.
Finally, we recommend that the inclusion of non-
nationals and internally displaced persons explicitly in
States’ SDG metrics framework be anchored in the
Brolan et al. International Journal for Equity in Health (2017) 16:14 Page 3 of 4

4. international human right to health, which in turn re-
quires appropriate financing allocations as well as robust
monitoring and evaluation processes that can hold
technocratic decision-makers accountable for progress.
Indeed, it is imperative to acknowledge that all seven
billion of us are potentially non-nationals or displaced
persons, that we are all human, and that there can be no
sustainable development without dignity for all. Human
health and planetary survival knows no borders.
Abbreviations
Go4Health: Goals and Governance for Global Health research consortium;
IOM: International Organization for Migration; MDGs: Millennium
development goals; SDG: Sustainable Development Goals; UN: United
Nations; UNHCR: United Nations High Commissioner for Refugees;
WHO: World Health Organization
Funding
This study was supported by the following agencies: Project Go4Health,
funded by the European Union’s Seventh Framework Program, grant
HEALTH-F1-2012-305240; by the Australian Government’s NH&MRC-European
Union Collaborative Research Grants, grant 1055138; by the Canadian
Institutes of Health Research Operating Grant: Ethics.
Authors’ contributions
CEB drafted the original manuscript, and all authors contributed to revisions.
All authors read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Ethics approval and consent to participate
This commentary presents the view of the authors and does not present
empirical data collected expressly for this purpose. Hence, no ethical
clearance was needed nor sought.
Author details
1
School of Public Health, University of Queensland, Queensland, Australia.
2
Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
3
Global Studies Institute/Faculty of Law, University of Geneva, Geneva,
Switzerland. 4
Law and Development Research Group, Faculty of Law,
University of Antwerp, Antwerp, Belgium. 5
University of Nairobi, Nairobi,
Kenya. 6
Center for the Study of Governance and Equity in Health Systems
Guatemala City, Guatemala, Guatemala. 7
Center for International Health,
University of Bergen, Bergen, Norway.
Received: 31 August 2016 Accepted: 14 December 2016
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